Case Presentation: A 44-year-old male with a history of i cirrhosis of liver secondary to chronic hepatitis C,and Illicit drug use presented from a jail to a regional medical center with abdominal discomfort and jaundice which started 2 weeks ago. The patient was diagnosed with acute hepatitis A infection by positive HAV IgM and treated conservatively for 5 days as inpatient. His total bilirubin on discharge was 12, which however trended up to 19 on follow up visits. The patient was admitted to our university hospital for further management. On admission, the patient’s vitals were temp. of 98.3, HR of 90/min,BP of 140/94 mm hg and oxygen saturation of 97 % on room air . . His physical examination was notable for jaundice, mild abdominal distension with diffuse tenderness and pitting pedal edema, suggestive of decompensated cirrhosis. His laboratory tests revealed white blood cell count of 2,700 /μL, platelet count of 82,000 /μL, AST of 143 U/L, ALT of 132 U/L, alkaline phosphatase of 135 U/L, a total bilirubin of 19.3 mg/dL with direct bilirubin of 16.2, and INR of 1.5. Hepatitis A IgM was positive, but the patient was also noted to have had positive hepatitis A IgG 5 months prior. The patient denied hepatitis A infection in the past. Further workup found patent hepatic vasculature on ultrasound and no infection on ascitic fluid analysis. The patient was determined to have acute hepatitis A infection as a likely cause for his abdominal pain and jaundice with decompensated cirrhosis. The patient was started on furosemide, spironolactone, and lactulose. His hospital course was complicated by hepatic encephalopathy and uncontrolled ascites requiring 2 therapeutic paracentesis. The patient improved after adding Rifaximin and titrating diuretics. His total bilirubin however continued to trend up and remained elevated at 25.6 on the day of discharge.
Discussion: Since 2017, outbreaks of hepatitis A in multiple states have been reported among population who use illicit drugs and/or are homeless . In Kentucky, 2769 cases have been reported by November 2018. 68% (1538) of outbreak-associated acute hepatitis A cases reported use of illicit drug use without homelessness, 10% (236) reported both homelessness and illicit drug use, 2% (45) reported homelessness without illicit drug use. Of note, 20% (456) had none of the two risk factors. Hepatitis A transmission is believed to occur through person-to-person contact and hepatitis A vaccines are recommended for prevention. Our incarcerated patient with a history of drug abuse and cirrhosis had shown immunity against hepatitis A but developed acute hepatitis A. Similar but different scenarios have been reported in the literature in the setting of non-sustained immunity (loss of HAV IgG over a few years) or vaccine failures in HIV-positive patients likely due to compromised immune system .
Conclusions: This case illustrates the importance of including acute hepatitis A infection in the differential diagnosis in patients previously immunized to hepatitis A, especially when they have chronic diseases which can compromise the immune system.